| MEMBER
INFORMATION: |
| NAME: |
_____________________________________ |
| TITLE/POSITION: |
_____________________________________ |
| DEPARTMENT/MAJOR: |
_____________________________________ |
| UNIVERSITY: |
_____________________________________ |
| MAILING
ADDRESS: |
_____________________________________ |
| CITY: |
_____________________________________ |
| STATE: |
_____________________________________ |
| ZIP: |
_____________________________________ |
| EMAIL
ADDRESS: |
_____________________________________ |
CHECK
TYPE OF MEMBERSHIP:
|
REGULAR
MEMBERSHIP ($10/year) ___
GRADUATE
STUDENT ($3/year) ___
UNDERGRADUATE
STUDENT ($1/year) ___
|
| PHONE
NUMBER (WORK): ___________________________ |
PHONE
NUMBER (HOME): ___________________________ |
| AREAS
OF INTEREST AND/OR EXPERTISE: |
_____________________________________
_____________________________________
_____________________________________ |